<form action="<?php echo $this->getFormAction();?>" method="post" id="feedback_form">
<input type="hidden" name="type" value="4">
<input type="hidden" name="page" value="feedback">

<div class="poll-form js_corner_10">
	<?php echo $this->getChildHtml("feedback_poll");?>
</div>


<div class="feedback group-select">
	<div class="input-field-set">
		<div class="input-box">
			<label for="salutation"><?php echo $this->__("Salutation");?></label>
			<span class="required">*</span><br />
			<select name="title" style="width:80px;">
				<option value="1" <?php echo ( $this->getFormData()->getData('title') == 1 ) ? 'selected="selected"':'';?>><?php echo $this->__("Mr.");?></option>
				<option value="2" <?php echo ( $this->getFormData()->getData('title') == 2 ) ? 'selected="selected"':'';?>><?php echo $this->__("Mrs.");?></option>
				<option value="3" <?php echo ( $this->getFormData()->getData('title') == 3 ) ? 'selected="selected"':'';?>><?php echo $this->__("Miss");?></option>
			</select>
		</div>
	</div>
	
	<div class="input-field-set">				
		<div class="input-box">
			<label for="firstname"><?php echo $this->__("First Name");?></label>
			<span class="required">*</span><br />
			<input type="text" name="first_name" value="<?php echo $this->getFormData()->getData('first_name');?>" class="input-text required-entry"  style="width:240px;">
		</div>
		<div class="input-box">
			<label for="lastname"><?php echo $this->__("Last Name");?></label>
			<span class="required">*</span><br />		
			<input type="text" name="last_name" value="<?php echo $this->getFormData()->getData('last_name');?>" class="input-text required-entry" style="width:240px;">
		</div>
		
	</div>
					
	<div class="input-field-set">
		<div class="input-box">
			<label for="telephone"><?php echo $this->__("Contact Telephone");?></label>
			<span class="required">*</span><br />		
			<input type="text" name="tel" value="<?php echo $this->getFormData()->getData('tel');?>" class="input-text required-entry" style="width:240px;">
		</div>
		<div class="input-box">
			<label for="telephone"><?php echo $this->__("Email Address");?></label>
			<span class="required">*</span><br />		
			<input type="text" name="email" value="<?php echo $this->getFormData()->getData('email');?>" class="validate-email input-text required-entry" style="width:240px;">
		</div>
	</div> 
		
	<div class="input-box">
		<label for="salutation"><?php echo $this->__("Feedback Or Comment");?></label>
		<span class="required">*</span><br />			
		<textarea name="content" rows="12" cols="50" class="enquiry_text required-entry" style="width: 500px;height:80px;color:#888;"><?php echo $this->getFormData()->getData('content');?></textarea>

	</div>	
	
	<div class="validation">	
		<label for="salutation"><?php echo $this->__("Verification:");?></label>
		<span class="required">*</span><br />		
		<img src="<?php echo $this->getUrl("contacter/index/validation");?>?width=80&amp;height=23">
		<input type="text" name="validation" value="" class="input-text required-entry" style="width:50px;">	<br />			
		<span class="tips"><?php echo $this->__('Type the characters you see in the picture.');?></span>
	</div>
	
	<div class="submit_button">
		<button class="button js_corner_4" type="submit"><span><?php echo $this->__("Submit Feedback");?></span></button>
	</div>
</div>
</form>
<script type="text/javascript">
//<![CDATA[
var dataForm = new VarienForm('feedback_form', true);
//]]> 
</script>